Today, we're going to look at a patient with a complication of schistosomiasis. To introduce everybody, the patient's name is Justin. [FOREIGN] Justin. >> [FOREIGN] >> [FOREIGN]. >> [FOREIGN]. >> [FOREIGN]. [FOREIGN] So, this patient then, is a patient who is in our wards, who was admitted with a complication of schistosomiasis. We have our final year medical students here, from KCMC and, and some visitors. And the patient presents with a complication of, what we think is just schistosomiasis. Now Justin, he's aged 45. And he comes from, from an area of Tanzania called Same. Which is on the way to Tanga. And it's near the mountains, isn't it? >> Yes. >> And his family has rice fields. And what I'd like you now to do is just to ask Justin, did he ever work in rice fields or has he ever worked in rice fields? That's number one, and number two, was he ever treated for schistosomiasis? [FOREIGN]. >> Mm-hm. >> Yes. >> Yes, he's worked in rice fields. Yeah. >> [FOREIGN]. >> Mm-hm. >> And he's been treated for schistosomiasis. >> Yes. >> So he's actually been treated for it in the, diagnosed in the past. Now, the reason he comes in to us is he presents with what we call. A major complication of schistosomiasis, that is gross hematemesis, vomiting blood. And to recap his history, he was admitted to us on the 31st of March, today is the 8th, isn't it? So that's nine days ago. >> 9th, 9th. >> It is the 9th. Okay. And that's just my age. And I'll read out the story here. He vomited blood approximately started three days ago, and the blood was full of clots. Copious estimated to be somewhere around half a litre. On the first day, the second day it continued, and, he was admitted to us on the 31st. There is a past history. The past history is that he had a procedure done at another hospital where they looked down into his stomach and found the source of the bleeding. He bled previously in 2012. To the, with the s, exactly the same as he did in late March this year. At that time he was found to have esophageal varices. What we're going to learn today, is that Justin has a major complication of schistosomiasis, called portal hypertension. The consequence of that is varices at the junction of what we call the portal systemic veins at the lower end of the esophagus, and he presents with bleeding. Now, clinically I've given you his history. He has one child. There is hist, history of some alcohol intake, but very modest. Now, so, the important thing to point out is on examination, his hemoglobin was down to 3.5 grams and we have already transfused him three units of blood and his last hemoglobin, when you checked it was 5.1. Now your hemoglobin and my hemoglobin is around 15 grams. So he's at a critical level with three, and that'll give you, ide, some concept of the extent of the bleeding. But how do we examine for the disease clinically? Well today, Justin, [FOREIGN] We're going to look at his abdomen. And when you look at his abdomen the first thing that strikes you is the distension, that abdomen is distended. The umbilicus is now flattened or out and if you look carefully the abdomen looks too full. And that brings up the examination of the abdomen and the best way to do that is to put Justin lying flat. Now can you lower the end of the bed for me. Secure it in this way. Lie down for me, Justin. So the first thing we do on an abdomen is inspect it, and if you look from the side of the bed, you can see it distended, and if you look from the end of the bed, you see it uniformly distended. And then we palpate it. That's the way we examine. We just start in the right iliac the right side, and gradually move around the abdomen. And straight away when I come up here, I feel a mass. And then I come across the right side of the abdomen, I don't feel anything special. Now I go back to investigate that mass. And I put my hand very gently, looking at his face all the time, and I can feel a mass here. that's his spleen. His spleen now is enlarged because of the consequence of schistosomiasis. I will explain a bit later how that can happen. You see the edge of it there? And I'll confirm that, take a deep breath in. Out. So his spleen comes down and hits my fingers and clinically we can just confirm that by tapping it. And I can hear a little area of dullness. I'm feeling for his liver. Justin [FOREIGN]. And nothing happens. And again Hema. And he doesn't have a big liver. These patients often don't have a big liver because schistosomiasis is essentially. Affects the portal system rather than the liver. The liver is relatively spared, it can be enlarged. And finally he does have some free fluid and we can demonstrate that in the following manner. Resonate down. And now, Justin lie on your left side and you wait 10 seconds, let the fluid go over and if you hear the sound now, listen. Resonant, okay? And dull here. So there, there's been some shifting of the fluid and that confirms there's fluid in there. The last thing I want to demonstrate with Justin, is the state of his anemia clinically. The way we do that at the bedside is we look at the hands are pale. You see them compared to mine? If if you could put yours their, for comparison. Here, and you see the pallor. >> [INAUDIBLE] >> That's the anemia that they get. So clear. And then confirm that by looking at his conjunctiva. They're pale. And open his mouth and his tongue is pale. Now that concludes the examination of Justin. Thank you.
